Roots Client Weekly Update : Roots Wellness Center

Client Name*

First Last

Primary Counselor*

TREATMENT DETAILS

Move-in Date:*

SUBSTANCE USE & WITHDRAWAL ASSESSMENT

Have you consumed any of the following substances since your last update?*

Check all that apply

Are you currently receiving medication assisted treatment?*

What is your current dose?*

How long have you been at this dose?*

Please describe any withdrawal symptoms you may be experiencing:*

PHYSICAL HEALTH & WELLNESS

Please rate how physically “well” you have felt this week:*

Explain:*

Any new medical/health issues?*

Yes
No

Describe:

Sleep Quality?*

How many hours per night?*

How many regular, quality meals do you eat on an average day?*

1
2
3
4 or more

Do you want to meet with a nutritionist?*

yes
no

Any appointments this week?*

Yes
No

What/When?

Did you have any Medication changes this week?*

Yes
No

What/When?*

What are you doing for Physical Activity?*

EMOTIONAL, BEHAVIORAL & MENTAL HEALTH

What was your biggest accomplishment this week?*

Have you had any thoughts of self-harm this week?*

No
Yes

Have you acted on any thoughts?*

No
Yes

Please talk to a staff member as soon as possible!

Rate your overall mood this week:*

Rate your overall stress level this week:*

Biggest stressors this week:*

What two coping skills have you used this week?

RECOVERY MOTIVATION AND PARTICIPATION

What group did you enjoy the most?*

Nutrition
Mental Health
Primary Counselor
Gender Specific Group
Make-up Group

What is your primary motivation for being in recovery/treatment?*

My Own Goals/Health
Probation/Courts
Child Protection
Housing
Family/Partner
Something Else

Please tell us how excited you've been to do the following activities this week:

Treatment Group:*

Attending and Sharing in Group

Other Treatment Appointments:*

Individual Counseling, Therapy, Peer Support

Other Recovery Activities:*

Recovery Meetings, House Meetings, Probation

What is your main goal right now?*

RELAPSE PREVENTION/RECOVERY MANAGEMENT

How confident have you felt in your recovery/sobriety?*

Extremely Confident
Very Confident
Somewhat Confident
Not Very Confident
Not at All Confident

Please identify any triggers that you’ve experienced this week:*

Check all that apply

Have you been having trouble with any of the following behavioral challenges?*

Check all that apply

RECOVERY ENVIRONMENT, RELATIONSHIPS & SUPPORT NETWORK

Are you in a recovery residence?*

Yes
No

Have you had any changes to your living environment and is your counselor aware?*

Yes
No

How many supportive relationships do you currently have?*

Who do you consider your primary support presently?*

How often do you call/text/chat with your support network?*

How often do you spend face-to-face time with your support network?*

How often do you attend mutual/recovery support groups?*

Do you have a sponsor/recovery coach?*

Yes
No
Working on it

How often do you talk to them?*

Rate how “connected” you feel to others around you:*

What are you doing for fun/recreation?*

How are things with your sober house leader/peers?*

Do you have any probation/court/CPS meetings coming up?*

No
Yes
N/A

Details:*

Are you following all of your legal requirements?*

No
Yes
N/A

If it applies, how is work/school going for you?*

Please rate your relationship with your counselor:*

What can they do to improve the relationship?*

What can you do?*

What do you like most/least about this program?*

What would make the program better?*

Anything else you’d like us to know?